BENNETT HEALTHCARE INC
GOODING, ID  83330

Medicare Provider Number: 135134
Cost report status: Settled Without Audit
[Record Code 1241934 - 2010]

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RATIO OF COST TO CHARGES FOR ANCILLARY AND OUTPATIENT COST CENTERS Provider CCN: 135134
PERIOD:
FROM 11/01/2018
TO 12/31/2018
WORKSHEET C
Cost Center Description Total ( from Wkst. B, Pt. I, col. 18 ) Total Charges Ratio ( col. 1 divided by col. 2 )  
1 2 3
ANCILLARY SERVICE COST CENTERS
40 Radiology ### ### ### 40
41 Laboratory ### ### ### 41
42 Intravenous Therapy ### ### ### 42
43 Oxygen (Inhalation) Therapy 43
44 Physical Therapy ### ### ### 44
45 Occupational Therapy ### ### ### 45
46 Speech Pathology ### ### ### 46
47 Electrocardiology 47
48 Medical Supplies Charged to Patients ### ### ### 48
49 Drugs Charged to Patients ### ### ### 49
50 Dental Care - Title XIX only 50
51 Support Surfaces 51
52 Other Ancillary Service Cost 52
OUTPATIENT SERVICE COST CENTERS
60 Clinic 60
61 Rural Health Clinic (RHC) 61
62 FQHC 62
63 Other Outpatient Service Cost 63
71 Ambulance 71
100 Total ### ###   100
FORM CMS-2540-10 (05/2011) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-2, SECTION 4123)
05-11   Rev. 1